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  #1  
Old 05-23-2012
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Question what is next step in her atypical chest pain ?

A 58-year-old woman is evaluated in the emergency department for substernal chest pain of 18 hours' duration. She escribes the pain as a tightening that is not associated with eating or exertion and that radiates to the neck. The pain is not accompanied by dyspnea, nausea, or diaphoresis and is not associated with exertion. She also reports symptoms of occasional heartburn and acid regurgitation. She had a similar episode of substernal chest pain 1 month ago, and an exercise stress test that achieved 90% her predicted maximal heart rate showed no ischemia. The patient's medical istory is otherwise unremarkable.
On physical examination, temperature is 37.2°C (99.0°F), blood pressure is 130/74 mm Hg, pulse rate is 88/min, and respiration rate is 16/min; BMI is 32. The cardiopulmonary examination is normal. Electrocardiography shows nonspecific ST-segment and T-wave abnormalities, which are unchanged from several previous examinations.
Which of the following is the most appropriate management for this patient?

(A) Ambulatory esophageal pH monitoring
(B) Coronary angiography
(C) Esophagogastroduodenoscopy
(D) Oral proton pump inhibitor therapy
(E) Repeat exercise stress test
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  #2  
Old 05-23-2012
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im not sure but its between esophageal pH monitoring and PPI trial therapy.
I read somewhere that resolution of reflux symptoms with a PPI trial is the best initial step in a suspected case of GERD.
But since the question stem is trying to rule out MI should we do an esophageal pH monitoring first or start with PPIs?
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Old 05-23-2012
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-pt age >40 +dyspepsia=C.
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Old 05-23-2012
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Since the dx is relatively unclear i will go with ph monitoring first, and this pt dont hv alarm sx for EGD, like dysphagia, anemia, weight loss…
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Old 05-23-2012
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diagnosis is unclear.... not sure if its GERD.
(no specific history of association with food/position/burning nature etc)

monitor esophageal ph

pg 244 mtb 2
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Old 05-23-2012
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Quote:
Originally Posted by bisho View Post
Since the dx is relatively unclear i will go with ph monitoring first, and this pt dont hv alarm sx for EGD, like dysphagia, anemia, weight loss…
Thinking in lines of Gerd ,more than 45 is an alarm symptoms as per Kaplan. Rest urexpln matches ditto with actualexpl.... So???
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Old 05-23-2012
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Well, my answer is D
becoz PPI admin is both diagnostic and therapeutic as pt has occasional history of heart burn and regurgitation, if the patients doesnot responds to PPI then 24 hour Ph monitoring should be done.
and regarding the EGD, if pt > 45 with definative PUD then you will Scope/EGD to exclude gastric cancer
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Old 05-24-2012
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Quote:
Originally Posted by tyagee View Post
Thinking in lines of Gerd ,more than 45 is an alarm symptoms as per Kaplan. Rest urexpln matches ditto with actualexpl.... So???
every source mention a different ans
Uworld say do EGD if
1. Nausea vomiting
2. Weight loss, anemia or melena/blood in the stool
3. Long duration of symptoms (>1_2 years), especially in Caucasian males >45 years old
4. Failure to respond to proton pump inhibitors

mtb 2
case is obvious --> PPI, not obivious --> ph monitor and EGD is done in
signs of obstruction, Weight loss, anemia or melena/blood in the stool, Long duration of symptoms, BUT DID'NT MENTION AGE (i dont know the last update about this topic, but we used to count age previous as a risk)

so shall we do EGD or ph monitor ?? and i'm against to go directly with PPI, cuz of age ?? but its also possible
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Old 05-24-2012
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Quote:
Originally Posted by bisho View Post
every source mention a different ans
Uworld say do EGD if
1. Nausea vomiting
2. Weight loss, anemia or melena/blood in the stool
3. Long duration of symptoms (>1_2 years), especially in Caucasian males >45 years old
4. Failure to respond to proton pump inhibitors

mtb 2
case is obvious --> PPI, not obivious --> ph monitor and EGD is done in
signs of obstruction, Weight loss, anemia or melena/blood in the stool, Long duration of symptoms, BUT DID'NT MENTION AGE (i dont know the last update about this topic, but we used to count age previous as a risk)

so shall we do EGD or ph monitor ?? and i'm against to go directly with PPI, cuz of age ?? but its also possible
-present of alarm symptoms in pt age <45.but any pt above 45 with dyspepsia should go for it.
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  #10  
Old 05-24-2012
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Guys the guidelines dont count age, its like those mentioned by uW
http://guideline.gov/syntheses/printView.aspx?id=16427
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